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It is important at the outset to agree on what we understand by the words humanitarian and humanitarianism. In everyday conversation, when we describe a person or an act as “humanitarian”, we generally mean that the person or their actions and intentions are good and that they are acting for the overall benefit of mankind or at least a portion of it. Humanitarianism, therefore, has similarities in this context to the concept of altruism. The concept of humanitarianism, certainly in the West, arose particularly in the mid-to-late 19th century when it was linked to the word ‘humane’, and associated with the many social reforms that were then taking place. Of particular importance in the genesis of humanitarianism was the work of Henri Dunant, who founded the International Committee of the Red Cross (ICRC) in 1863 and was instrumental in the establishment of the Geneva Conventions. It was the suffering and neglect of the wounded in battle that inspired Dunant to write his seminal work, A Memory of Solferino, and shortly afterwards to galvanise the formation of the ICRC in Geneva as an independent organisation that advocated for the better treatment of those wounded in war. He also advocated for the establishment of national groups of volunteers to assist the wounded in times of conflict. 1 One year after the ICRC was founded, the first Geneva Convention was drawn up and agreed. This treaty obliged armies to care for wounded soldiers, whichever side they were on, and the Red Cross emblem for medical services was introduced.

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According to the UN, a disaster occurs when there is a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability, and capacity, leading to one or more of the following: human, material, economic, and environmental losses and impacts. 1

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Earthquake tremors occur with the movement of the earth’s crust along tectonic plates. Such tremors occur every day, often large ones, with most, fortunately, occurring out at sea and posing little or no threat to human populations.

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A humanitarian emergency is an event, or series of events, that represents a critical threat to the health, safety, security or wellbeing of a community or other large group of people, usually over a wide area. 1 The need for medical assistance in such humanitarian emergencies, and disasters in general, continues to rise. The UN emphasises too that humanitarian emergencies created by conflicts are widespread and protracted, with significant injuries to the civilian population. However, where those providing medical care to the ill and injured in war might once have expected a degree of protection, attacks on healthcare 2 , 3 facilities and healthcare workers have increased significantly. In war, there is the added potential complexity of receiving and treating contaminated casualties from the use of chemical, biological, or radionuclear weapons. An additional and distressing confounding factor has been the increasing use of rape and gender-based violence as tactics of war.

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Just as the response to the earthquake in Armenia in 1988 gave rise to a series of UN initiatives, 1 , 2 so concerns about the emergency medical response to the earthquake in Haiti in 2010 would give rise to the WHO Emergency Medical Teams (EMT) Initiative.

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Perhaps the biggest disaster of all is war. Armed conflicts precipitate major humanitarian emergencies, in the injuries they create and especially in the disruption they bring to society and to the delivery of healthcare. Women and children are particularly vulnerable, and a caesarean section, for example, is one of the commonest surgical operations to be carried out in a humanitarian crisis, even in a conflict zone. 1

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Modern experience has shown that if emergency medical humanitarian assistance is to be of maximum benefit, and particularly if it is not to cause unintended harm, then those who respond must be well prepared, equipped, and practised.

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If aid is to do the most good for the most people, it must be targeted appropriately. To do this, a rapid needs assessment should be carried out as soon as possible, and in direct consultation with the host authorities. This may be done by the deploying team, or it may already have been done by international agencies working in tandem with the local authorities.

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This book is not intended to describe in detail the management of specific clinical conditions. There are a number of established, practical courses 1 , 2 , 3 that comprehensively cover these issues, as well as detailed surgical texts and handbooks. 4 There are, however, some important general principles and adaptations that must be applied when managing trauma and other health conditions in humanitarian emergencies, and with limited resources. A particularly important concept to accept is that whatever care one perceives one’s team to have deployed to provide, for example trauma care, the local population will always see the team simply as a medical facility to which they will present with whatever their health concern happens to be. It is essential, therefore, that all teams are prepared to respond to a wide range of medical presentations with immediate treatment protocols and onward referral pathways.

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A field hospital must have the capacity to establish a separate tent as a designated isolation area. The tent should be well ventilated with fresh air and with a 2-metre gap between beds. It must be clearly marked, and patients must have access to separate toilet and handwashing facilities. This isolation tent should not be a medium- to long-term solution, but rather a short-term measure as referral and transfer of these patients to a specialist isolation and treatment is prioritised.

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The word ‘triage’ originates from the French word trier, meaning to sort. Baron Larrey introduced the concept into Napoleon’s army where patients were sorted (triaged) into categories of urgency based on their clinical condition and not their military rank.

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Responding to humanitarian emergencies carries with it a number of ethical dilemmas to which there are often no hard and fast answers but for which team members must be prepared. No matter how well resourced the team, the scale of the emergency may be such that care that might be given in other circumstances cannot be provided or must even be withheld. Decisions regarding when to treat or when not to treat are amongst the most difficult. The burden of decision-making need not fall on the shoulders of one person. Teams should have identified before deployment an emergency ethical committee amongst their numbers to which team members can refer such difficult decisions and receive a rapid consensus view. It is important that the team understands such collective responsibility.

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Humanitarian medicine is complex, often difficult, but can be very rewarding. It is, however, important to recognise that like any other field of medical practice, it requires training, experience, and appropriate qualifications. There are national and international structures, as described in this book, that are available for the coordination of international emergency responses and matching their capabilities to the needs they have identified. Foremost among these is the Emergency Medical Teams Initiative at WHO, a full knowledge of which is essential for anyone who wishes to work in the humanitarian sector. Given the developments in the organisation and structure of the international emergency medical response there is no place now for inexperienced individuals to respond uninvited. The potential for doing more harm than good is too great. Humanitarian work brings many rewards and I encourage the reader to consider deployment. It also carries emotional and ethical pressures, the effects of which though can be mitigated by adequate preparation and training, and only deploying with an experienced, well established, and well-resourced organisation. If you are interested, do consider the following. First complete your full training in whatever is your background specialty/discipline and attend additional specialist humanitarian skills courses. During or after your clinical training, consider gaining additional qualifications such as a Masters degree in public health, disaster management, humanitarian and conflict studies etc. These are very valuable in expanding your understanding of how humanitarian emergencies arise and evolve. In addition, explore clinical courses leading to diplomas, for example in the UK there is “Medicine in Conflict and Catastrophe” at the Society of Apothecaries, or Tropical Medicine at the London/Liverpool Schools. These provide further opportunities to expand both knowledge and skill base. Finally join the humanitarian community. Most large NGOs will have their support groups, volunteers, and fundraisers. At many universities they will have their own student groups. An important development in the humanitarian community has been the establishment of a “professional home” in the Faculty of Remote Rural and Humanitarian Healthcare at the Royal College of Surgeons of Edinburgh. This is open to all those involved in this work and from anywhere in the world.